Extraction Of Tacks Nails And Large Headed Foreign Bodies From The Tracheobronchial Tree

In cases of this sort the point presents the
same difficulty and requires solution in the same manner as mentioned
in the preceding paragraphs on the extraction of pins. The author's
inward-rotation method when executed with the Tucker forceps is ideal.
The large head, however, presents a special problem because of its
tendency to act as a mushroom anchor when buried in swollen mucosa or
in a fibrous stenosis (Fig. 83). The extraction problems of tacks are
illustrated in Figs. 84, 85, and 86. Nails, stick pins, and various
tacks are dealt with in the same manner by the author's inward
rotation method.

Hollow metallic bodies presenting an opening toward the observer may
be removed with a grooved expansile forceps as shown in Figs 23 and
25, or its edge may be grasped by the regular side-grasping forceps.
The latter hold is apt to be very dangerous because of the trauma
inflicted by the catching of the free edge opposite the forceps; but
with care it is the best method. Should the closed end be uppermost,
however, it may be necessary to insert a hook beyond the object, and
to coax it upward to a point where it may be turned for grasping and
removal with forceps.

[FIG. 83.--Mushroom anchor problem of the upholstery tack. If the
tack has not been in situ more than a few weeks the stenosis at the
level of the darts is simply edematous mucosa and the tack can be
pulled through with no more than slight mucosal trauma, provided
axis-traction only be used. If the tack has been in situ a year or
more the fibrous stricture may need dilatation with the divulsor.
Otherwise traction may rupture the bronchial wall. The stenotic tissue
in cases of a few months' sojourn maybe composed of granulations, in
which case axis-traction will safely withdraw it. The point of a tack
rarely projects freely into the lumen as here shown. More often it is
buried in the wall.]

[168] [FIG. 84.-Schema illustrating the mushroom anchor problem of
the brass headed upholstery tack. At A the tack is shown with the head
bedded in swollen mucosa. The bronchoscopist, looking through the
bronchoscope, E, considering himself lucky to have found the point of
the tack, seizes it and starts to withdraw it, making traction as
shown by the dart in drawing B. The head of the tack catches below a
chondrial ring and rips in, tearing its way through the bronchial wall
(D) causing death by mediastinal emphysema. This accident is still
more likely to occur if, as often happens, the tack-head is lodged in
the orifice of the upper lobe bronchus, F. But if the bronchoscopist
swings the patient's head far to the opposite side and makes
axis-traction, as shown at C, the head of the tack can be drawn
through the swollen mucosa without anchoring itself in a cartilage. If
necessary, in addition, the lip of the bronchoscope can be used to
repress the angle, h, and the swollen mucosa, H. If the swollen
mucosa, H, has been replaced by fibrous tissue from many months'
sojourn of the tack, the stenosis may require dilatation with the
divulsor.]

[FIG. 85.--Problem of the upholstery tack with buried point. If pulled
upon, the imminent perforation of the mediastinum, as shown at A will
be completed, the bronchus will be torn and death will follow even if
the tack be removed, which is of doubtful possibility. The proper
method is gently to close the side curved forceps on the shank of the
tack near the head, push downward as shown by the dart, in B, until
the point emerges. Then the forceps are rotated to bring the point of
the tack away from the bronchial wall.]